Johannesburg - This is a grim time of year for a hospital in the Eastern Cape, where mattresses are laid on floors to cope with the stream of young men with severe injuries from botched circumcisions at initiation ceremonies.

Some patients with amputations, a doctor says, were told by their handlers that their genitals would grow back, reflecting a fog of misinformation that makes it hard to stop what has become an annual health crisis.

It wasn't supposed to be this way.

The traditional ritual, which goes back centuries, is meant to usher youths into manhood, inculcating them with the responsibilities to become valued members of their community.

Former president Nelson Mandela wrote about the spiritual meaning of his own circumcision in the same province where the Holy Cross Hospital is struggling to handle the influx of injured males.

At least 60 males have died at initiation schools in the Eastern Cape since the start of the initiation season in May, health officials confirmed.

Thirty of them died in the last six weeks, and 300 others were hospitalised with injuries.

Manual

Dingeman Rijken, a doctor at Holy Cross Hospital, has treated so many cases that he is campaigning for better practices at the ceremonies, circulating a training manual that calls for proper medical precautions.

The manual contains graphic images of circumcisions and offers an ideal method of performing the procedure, which he's shared with people involved in initiation ceremonies around Eastern Cape's Pondoland region.

"It is becoming a psychological issue," said Rijken, who has treated 140 initiates in the last year and admitted another 150 for serious injuries.

"I have had to tell eight boys this season that they've lost their glans or parts of their penis, so it is a health problem. We can't run away from it, we need to address it."

He said nurses struggle to keep up with the overflow of more than 68 initiates who were admitted in the last two weeks with badly infected genitals, dehydration or other serious injuries.

The worst of the injuries occurred after botched circumcisions performed by inexperienced traditional nurses, who use the same spear on multiple initiates without protecting against the spread of infections, then cover up wounds with tightly wrapped bandaging that cuts off blood supply to the area.

After about 10 hours the genitals can become gangrenous and in some cases permanently damaged, but many initiates do not seek hospital treatment for another five to 10 days, Rijken said.

By this time very little can be done. Doctors cannot perform surgery because initiates suffer from sleep deprivation and dehydration and are not in a condition to give consent.

In minor cases, Rijken cleans off loose gangrenes around the affected area, bandages it and treats it with antibiotics, which eventually may result in a partial amputation of the penis. In more serious incidents, boys wait a period of one to six weeks until the entire organ falls off, he says.

Initiations are mostly practiced, though not exclusively, by the Xhosa. Young males participate in the ritual as a formal preparation for adulthood, usually undergoing circumcision and survival tests in secluded sites.

Age

Most of the deaths in the Eastern Cape were in Pondoland, where the practice was banned in the 1820s by its then ruler, and then reintroduced in the last three decades as men who left their communities to work in mine fields were ostracised because they were not considered men if they were not circumcised, Rijken said, citing his research of its history.

Government legislation stipulates that participants should be at least 18, but parents can sign a consent allowing younger boys to participate.

Rijken has monitored more than 60 ceremonies and rescued several injured boys, and says he sees initiates mostly between ages 14 and 17, but has treated boys as young as 12 who are too young to understand the implications of losing their male organ.

He said initiates rarely complain about pain because they fear being beaten by nurses and ridiculed by peers for not properly observing a tradition that encourages initiates to develop a tough demeanor.

One patient had part of his injured penis "yanked off" as punishment for complaining, and those who suffer penile amputations are frequently told by handlers that their penises would grow back, Rijken said.

"But that's why we need to involve the community, to tell them it won't grow back," he said.

Like others who have spoken about the long-held tradition, Rijken believes it will take the combined effort of traditional leaders, provincial health departments and effective government regulation to end the killings and save the cultural practice, but he said it's time the community is educated on the dangers.

"At a certain point if you see so many boys are dying, then it's time to talk about it," he said.

"We want people to do away with the secrecy and get the community involved."

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